Equity and Practicality in Health Disparities Research

John R. Stone, MD, PhDCenter for Health Policy and Ethics

Creighton University School of Medicine

Learning Objectives• Explain meanings of “health equity” and

“healthcare equity.”• Understand links to equality, justice, and

respect.• Explain practical implications for health

disparities research.

Health DisparitiesClarity & Practicality

ClearDefinitions

Clear Indications• Healthcare• Social policy

Braveman et al. (2011) AJPH

Respect• Everyone has equal and substantial moral

worth and their equal worth is recognized, honored, and ensured.

Health Disparities• “Health differences that adversely affect

socially disadvantaged groups.”– “plausibly avoidable”– Assoc w/ “discrimination or marginalization”

• “Disparities in health and its determinants are the metric for assessing health equity.”

Braveman et al. (2011) AJPH

Equity & Disparities

Health Equity

• Core value

EliminateDisparitie

sBraveman et al. (2011) AJPH

Braveman et al. (2011) AJPH

Soc JusticeRights

HealthEquity

HealthDisparities

Equity & Practicality• In health disparities research

– The concept of health equity is practically important.• Yes/No (Example)

– The concept of healthcare equity is practically important.• Yes/No (Example)

Ethical Actions

Possible Actions

Ethical Actions

Practical = Possible

Practical = Possible & = “Plausible” =

= Reasonably Possible? or

=Should do, all moral factors considered

Equity & Practicality• Is the concept “health equity” practically

helpful in health disparities research?– Gives helpful ethical guidance and/or– Provides helpful new guidance and/or– Facilitates what should be done

Health Disparities Research• Is the concept of health equity of practical

significance? Is it practically helpful?• If so, how or why?

JusticeEquity

Equality

Equity, Rights, Health, Healthcare • Ethical Right to health/healthcare: 1o or 2o

(R1/R2)• Equitable H/Hcare

– Fair honoring of R1/R2– Not overridden by other Rs & additional ethical

factors as determined through a fair deliberative process

Equity (& Equality)• Feature of justice• Justice as Fairness

– Likes are treated alike (equality)– To each (grp, individ) what is due (e.g. equal

opportunity)– Priority to the worse off, especially worst off– Outcomes of a decision procedure that employs

appropriate ethical guidelines, including fair equality of opportunity for participation.

Equity in Health/Healthcare• Fair opportunity for a sufficient level of health*

– Just distribution of social determinants– Genuine access to needed healthcare– Needed healthcare

• Remediation of deficiencies, given no overriding ethical considerations

*Powers, M., & Faden, R. (2006)

Practicality & Disparities Research• Healthcare Equity

– Fair & substantial equal opportunity for access• Sort by challenges: poverty, language, education, etc.• Structural barriers: agencies, policies• System facilitators

– Equality after system entry• Quality improvement outcomes• System “treatment” (policies, procedures, personnel)

Causality & Practicality• “It must be plausible, but not necessarily

proven, that policies could reduce the disparities, including not only policies affecting medical care but also social policies addressing important nonmedical determinants of health and health disparities,

Braveman et al. (2011) AJPH

Health Equity, Social DisadvantageHealth Sciences Centers

• Does health equity, a form of social justice, require that health sciences centers work to eliminate unfair inequalities in social determinants that contribute to health disparities?

• Why/why not?• If so, how?

Equity: Health & Healthcare• Does health equity require that healthcare

institutions/systems assess outcomes by race/ethnicity, gender, sexual orientation, language, socioecon status, geographic location, etc.?

• Why/why not?• If so, how?

References• Braveman, P. A., Kumanyika, S., Fielding, J.,

Laveist, T., Borrell, L. N., Manderscheid, R., & Troutman, A. (2011). Health disparities and health equity: The issue is justice. American Journal of Public Health, 101 Suppl 1, S149-55.

• Powers, M., & Faden, R. (2006). Social justice: The moral foundations of public health and health policy. New York: Oxford Univ. Press.